Dybul: `We need to be more efficient'

At the Pacific Health Summit in London this week, the main theme centered on maternal and child health. But some of the discussion touched on HIV and TB issues, and many of the participants are important players in those worlds.

One is Dr. Mark Dybul, the former US global AIDS ambassador under President Bush and now the co-director and Distinguished Visiting Scholar in the Global Health Law Program at Georgetown University. In an interview with John Donnelly at the summit, he declined to talk about the current debate over levels of US funding for AIDS, saying that he didn’t want to interfere with the job of Dr. Eric Goosby, the current US global AIDS ambassador.

Dr. Mark Dybul, former US Global AIDS Ambassador

But Dybul had several provocative things to say about AIDS, inefficiencies in US government spending, and the future of the Global Fund. Obviously, his views are entirely his own, and, as in other posts, we hope that it sparks debate in the comments section.

Here are excerpts from the interview.

Q: You’ve been speaking out about the need to better integrate global health funding. What do you think should be done?

A: I think that because we’ve had this 10 years of enormous success with HIV and a lesser degree malaria, that we’ve seen what money can do. Money can really save lives. But I think the experience of the past decade has really shown us the limitations of dealing with a specific disease. You can now see the fault lines, the weakness of health delivery systems, and also see the inefficiencies of multiple programs with large sums of money that are only dedicated to a single approach. There’s more of a sense now that we need to be more efficient with the money that we have.

Q: But you have long argued that funding for the US global AIDS program also was strengthening health systems.

A: One of the greatest legacies of PEPFAR is it was the first time in history we’ve dealt with a chronic disease in development. Fighting a chronic disease requires you to build a health structure; people need to return to clinics on a regular basis for the rest of their lives. While there were very positive ripple effects from PEPFAR throughout the health system — the supply chain, the communications systems, the logistics systems, to name a few — it’s not an approach to systematically improve health delivery services. We’ve got to have a more efficient approach, which includes using disease-specific programs as an entry point to deliver health.

The end point in this is the health and happiness of and dignity of a human being. That’s what your focus is. We need to back up from that – we need to provide HIV care, childhood care, immunizations, maternal health services, TB care, malaria treatment. We just need to deliver them in a far more efficient and more effective way. We could be doing two to three times more with the money we’re spending than what we are doing today. That would happen if we had a more efficient way of delivery. And that view is not just mine, but also by the people in government holding the purse strings.

Q: Can you give me an example of an inefficiency in spending?

A: At PEPFAR, we created a supply chain system for drugs and materials. The intent was to build local capacity, not just to build a HIV supply chain. When the President’s Malaria Initiative was created, we told them we already have bed nets and (malaria drugs), use our supply chain system. We told them it may cost a little bit incrementally to get going. But they didn’t join us. They created their own supply chain system. That’s a great example of a non- integrated system that is not cost effective. That is just one example of many, believe me.

Q: In the US, there’s a lot of focus on the Global Health Initiative. But what should happen with the Global Fund to Fight AIDS, Tuberculosis and Malaria?

A: If we stepped back and said if we could design a system today to ensure the health and dignity of an individual, what would we do? We would fund national health strategies and well-planned and integrated service delivery so that people receive the services they need, at the time they need it. People are now talking about just adding maternal and child health to the Global Fund. But that would just be another inefficient add-on. Wherever it is humanly possible, they should put funding streams together – not for separate diseases — to get the best health care to individuals. It would serve the person better, and it would be much less costly. Just the transactions costs on these grants are huge. If we could transform the Global Fund to fund national health systems, and get integrated systems, that could be a radical shift for the better.

In Ethiopia, for instance, Minister Tedros (Adhanom Ghebreyesus) has restructured his Ministry. He doesn’t have line offices just for TB, HIV, malaria, or maternal health. He has groups that report to him on the health of the people, including, for instance, whether HIV services are provided. He wants to know the health outcome. He wants his Ministry to be dedicated to the health of the people. I believe that’s a better way to go.

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2 thoughts on “Dybul: `We need to be more efficient'”

This is yet symptoms of the long existing tension between specific disease control approaches and systems approaches or vertical versus horizontal. In my view, the disease specific approaches for HIV were appropriate at the time, but as the disease begins to take on a chronic pattern (thanks to the protracted vertical approach), it is only healthy that the debates slowly and carefully shifts towards an integrated approach, keeping in mind that not all countries are achieving the chronicity level, different countries are at different levels of the disease epidemiology and so at different levels of tackling the disease. Some countries have effectively minimised new infections, others are still have high levels of new infections, some have reached universal levels of ART access, others somewhere along the way. Of course the arguement that these vertical programs have just helped us expose the ‘rot’ in our health systems should not be ignored altogether.

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